HomeMy WebLinkAboutMaddyummies 06/01/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment
Type: RESIDENTIAL KITCHEN
In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and
Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:.
LORI SELSBERG
Whose place of business is:
MADDYUMMIES
No -]=Keil &IITIEeP► I
PERSON(S) IN CHARGE
MADISON SELSBERG
Permit Expires: June 01, 2016
License Number: RK -06
Food Fee: $100.00
BOARD OF HEALTH
Catherine Ann .Memory, Chairperson
,FOR BOARD OF HEALTH USE ONLY
Date received: Date : Approved By:
SE It
�(�(��l ESTABLISHMENT ���J/N|7- APPLICATION_,
` ^^~^^~^-~''`~~`-'~^~~-'`' PERMIT -
(Application n7ust be submitted at least 7 days prior to planned event)
1) Establishment Name:
2) Establishment Address
3) Establishment ailing Address nt)
A NA o2 -r349
4) Establishment Telephone No: -77-?_� 4-- 2Y5 2
5) Applicant Name & Title: C -D bz:J� 0'g=2_
6) Applicant Address
7)Applicant Telephone No' / (�i
' /�l| =ly
NOwners Name &Title
8>Owner Address (If different from oppicmnt):
1O)Establishment Owned By:
UAnAssociation
[]ACorporation
1�(\nhdividua|
[]APartnership
LJ Other legal Entity
/�4
11>Ife corporationorpartnership, give name, title, and home address of officers
or partner.
Name Title Address
12) Person Directly Responsible For Daily Operations (owner, person In charge, supervisor, manager etc.)
Name & Title:
Telephone No:
Emergency No:
Alt E -Mail,
13) District Or Regional Supervisor (if applicable)
Name &Title:
�
Address:
Telephone No:
24 Hour Emergency No:
Food Establishment Information
- — - ------ ----- --- - _ _ - - --- - - - -
14) WATER SOURCE: 15) SEWAGE DISPOSAL_ _.
DEP Public Water Supply No: (If appliclaJblee)) 16) No. of Food Employees:
17) GAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file.
Required as of 10/1/2001 in accordance with 105 CMR 590.
Please attach copy of certificate
19) Person Trained In Anti -Choking Procedures (If 25 Seats or more):M
20) Location: ❑ Permanent Location
❑ Mobile Mobile Start Date:
Mobile End Date:
Mobile Comments:
21) Length of Permit:
❑ Annual
❑ Seasonal
Sea, onal Dates:
Temporary �.
Temporary Start Date: 9 19
Temporary End Date: j
Temporary Time:
Rain Date:
22) Establishment Type
Retail ( Sq. Ft)
Food Service up to 100 or
up to 10' PHF display $75
❑ Food Service up to 101 -200
or up to 25' PHF display $100
❑ Food Service up to 201 +
or 25'+ PHF display $125
ci Food Service - Institution
Meals/Day)
❑ Caterer $25
❑ Milk & Cream $2
(j Mobile Food & Consession $50
❑ Mobile Food Temporary $25
❑ Manufacture Frozen Desserts/ice Cream
$5/freezer
❑ Pushcart $25
t-
Residential Kitchen
(A Retail Food $5
�# of Pushcarts:
El Retail Snack Food $10
❑ Tobacco Products No Fee
23) Food Operations Definitions: PHF - Potentially hazardous food (limeltemporalure controls required)
Non-PHFs - non -potentially hazardous food(no litneRemperature controls required)
(Check all that apply): RTE - ready -lo -eat foods (Ex. sondinehes, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
E]Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
❑ rY g Susceptible Population Facility
E] Reheating of Commercially
❑ Sale of Raw Animal Foods Intended _
Processed Foods for Service Within 4 Hours to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill
❑ Customer Self -Service of Non PHF and Non-�
❑ Customer Self-Servlce
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
Perishable Foods Only
Ice Manufactured and Packaged for
❑ 9
contact alternative, time as a public health
❑ Preparation of Non-PHFs
Retail Sate
control)
Other Food Operations
❑ Juice Manufactured and Packaged for
❑ Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
❑ Offers RTE PHF in Bulk Quantities
❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
[] Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
To be completed by the Board of Health
Total Permit Fee,,
Payment is due with application 0 waived
I, the undersigned, attest to the accur of the information provided ' ication and affirm
that the food
establishment operation vrill co wit 105 CMR
09-a I other applicab w. I have been instructed by the
board of health on how to obi n copi o R 590.
0 an a {ederal Food Code.
}� 24) Signature of Applicant:
f Pursuant to MGL Ch.62C, sec. 49A, I certify under the
pen 'es erjury that 1, to my best knowledge
and belief, have filed all state tax returns
and paid state taxes required under law. �}
K26) Social Security Number or Federal ID: /
26) Signature of individual or Corporate Name:
I certify under the penalties of perjury that I, to my best knowledge and belief,
have filed all State tax returns and paid all State taxes required under law.
* Signature of Widual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the cedit'ication clause is signed by
the applicant.
** Your Social Security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or tax
payment obligations, Licensees who fail to correct their non -filing or delinquency
will be subject to license suspension or revocation. This request is made under
the authority of Mass, General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
ivivw, inass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization
Address:
0
city/S
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2, am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp, insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees, [No workers' camp, insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. (No workers. comp, insurance req.)
Phone #:
( 91
Business Type (required):
5. 0 Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. [] Entertainment
10.❑ Manufacturing
11.[] Health Care
12.0 Other
*Any applicant that checks box N t mnst also rill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box # I .
lain an employer MW is providing ivorkers' compensation Insurance for my employees, Beloty is the policy inforination.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins, Lie.
Expiration Date:,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Inve.sdizations of the DIA for insurance coverage verification.
I do hereby cerqojituler the
that the informatlou prov1do4 aave I trite and correct.
Date: 16 )
Official use only, Do not Pyrite lit this area, to be completed by city or town offlelat
City or Town:
Pernilt/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person
%vmv.mass.gov/dia
Phone M.
0
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